Cumbler Ethan, Glasheen Jeffrey
Section of Hospital Medicine, Department of Internal Medicine, Division of General Internal Medicine, University of Colorado at Denver and Health Sciences Center, USA.
J Hosp Med. 2007 Jul;2(4):261-7. doi: 10.1002/jhm.165.
Hospitalists are frequently called upon to manage blood pressure after acute ischemic stroke. A review of both post infarction cerebral perfusion physiology and the data from randomized trials of antihypertensive therapy is necessary to explain why consensus guidelines for blood pressure management after stroke differ from those of other hypertensive emergencies. The peri-infarct penumbra is the central concept in understanding post ischemic cerebral perfusion. This area of impaired cerebral blood flow is dependent on mean arterial blood pressure and acute reduction of blood pressure may expand the area of infarction. Review of clinical trials fails to show benefit from reduction of blood pressure after ischemic stroke and current guidelines suggest antihypertensive therapy be employed if the systemic blood pressure is greater than 180/105 mmHg after tPA is employed, or 220/120 mmHg when tPA is not used. Induced hypertension remains a promising but unproven therapy in the acute setting, but the evidence for long term control of blood pressure to less than 140/80 mmHG for secondary prevention of stroke is strong. Adherence to guidelines is poor but it is recognized that current evidence is limited by a lack of trials in which blood pressure is titrated to a pre-specified goal, as is common in clinical practice.
急性缺血性卒中后，常需住院医师管理血压。有必要回顾梗死后脑灌注生理学以及抗高血压治疗随机试验的数据，以解释为何卒中后血压管理的共识指南不同于其他高血压急症的指南。梗死周围半暗带是理解缺血后脑灌注的核心概念。这个脑血流受损区域依赖于平均动脉血压，血压急性降低可能会扩大梗死面积。对临床试验的回顾未能显示缺血性卒中后降低血压有何益处，当前指南建议，使用组织型纤溶酶原激活剂（tPA）后若全身血压大于180/105 mmHg，或未使用tPA时血压大于220/120 mmHg，则应采用抗高血压治疗。在急性情况下，诱导性高血压仍是一种有前景但未经证实的治疗方法，但有强有力的证据表明，为预防卒中复发，长期将血压控制在低于140/80 mmHg是有必要的。对指南的依从性较差，但人们认识到，目前的证据因缺乏像临床实践中常见的那样将血压滴定至预先设定目标的试验而受到限制。
